Home Care Medical

Infusion Pharmacy Therapies Infusion services offered for home administration include short and long-term antibiotic therapy, pain management, hydration, chemotherapy and inotropic medications. Each patient’s plan of care is reviewed with their medical team and a customized clinical solution is provided. Antimicrobial Antimicrobial therapy is, by far, the most common infusion therapy provided in a patient’s home. Home Care Medical routinely supplies vancomycin, Rocephin®, nafcillin, Zosyn® and clindamycin for home use. Many other antimicrobials are appropriate for home infusion and Home Care Medical has the expertise to provide them for safe and effective use in the home. Antimicrobials can be infused via several delivery systems, depending upon the drug used and the needs of the patient. 1. The simplest administration is via gravity or IV push. Drugs given one or two times a day can be administered this way. This “low-tech” approach is easy for patients and caregivers to understand.

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2. Elastomeric pumps (Baxter Intermate,® Medpro AccuFlo,® etc.) can be used for “on-the-go” patients. These pumps look like a balloon in a bottle and can deliver medication at different rates and volumes depending upon the size of the unit and the bore size of the attached tubing. 3. Many of our therapies are administered via the Vista Basic® infusion pump, an in-patient standard in many hospitals. 4. For therapies that require dosing every 4-6 hours, or for continuous therapy, we use a programmable ambulatory pump (e.g. CADD Legacy Plus®). These pumps can be programmed to infuse a specific dose at the given interval prescribed and also maintain patency of the IV catheter by infusing a KVO rate between doses. Antimicrobials for this type of administration are supplied in one or two day bags so the patient or caregiver only needs to tend to the pump once every one or two days. Antimicrobials must be stable at room temperature to be administered using this system.

Home Care Medical | Infusion Pharmacy Therapies Chemotherapy Home Care Medical provides 5-fluorouracil (5-FU) therapy at home for many patients in Southeastern Wisconsin. We provide this medication in a manner appropriate for prescription requests by the various oncology clinics. Deliveries of medications and supplies are coordinated with the patient and are relative to physician appointments, lab value reviews and dose changes – per protocol. Programmable pumps are used to administer 5-FU in a safe, controlled manner. Other chemotherapy agents, such as Vincristine and Doxorubicin, can be safely administered in the home setting as well. Pain Management Treatment of patients to control pain is a significant part of Home Care Medical’s clinical practice. Many patients do not achieve adequate pain control with medications administered orally, rectally or transdermally. Through the use of programmable pumps (e.g. CADD Legacy® PCA), administration of potent IV, Sub-Q or intrathecal doses of narcotics are infused through a controlled pump. Continuous basal rates and on demand bolus doses help control pain. We routinely supply morphine sulfate and hydromorphone (Dilaudid) in this way. Medication is supplied in tamperresistant cassettes and programmable pumps are locked with a numerical code to prevent misuse or errors in the home. Parenteral Nutrition Our nutrition support team provides Parenteral Nutrition (PN) formula and supplies to meet a patient’s nutritional requirements. Our dietitian and pharmacists monitor and evaluate each patient’s individual needs. Home Care Medical is able to meet the needs of patients who require nutrition support via the parenteral route. Each patient receives a PN compounded for their specific needs. We do not use a standard “one size fits all” formula. Although we can provide some patients with a 2-in-1 formula, lipids separate, we most commonly provide a 3-in-1 PN, which provides for the individuals nutritional needs in a convenient one bag per day infusion. Our PNs are mixed in a class 7 clean room using a computer controlled mixing device to ensure sterility, accuracy and consistency of the compounding process. Patients administer their formula via pump (e.g. CADD Prizm®) and the goal is that the patients are totally self-sufficient within weeks of the start of their therapy at home. We have several patients who have been successfully receiving home PN for many years. Additional Therapies and Services Home Care Medical routinely provides the additional therapies as listed below. – Antiemetic (e.g. Zofran,® Kytril,® Anzemet®) – Cardiac (e.g. dobutamine, dopamine, milrinone) – Catheter Declotting (e.g. Activase®) – Catheter Maintenance (e.g. heparin, saline) – Chelation (e.g. deferoxamine)

– Colony Stimulating Factor (intravenous route) – Hospice Medication Program (e.g. Haldol,® Thorazine,® lorazepam, morphine, Dilaudid®) – Hydration (e.g. normal saline) – Immune Globulin (e.g. Gammagard,® Polygam®) – Steroid (e.g. Solumedrol®) As with all our therapies, we tailor our services to meet the needs of the patient, caregiver, physician and home nursing agency. Our pharmacy staff consists of pharmacists and pharmacy technicians with over 75 years of combined experience. We are always willing to discuss the possibility of new therapies for home administration or new protocols for existing home infusion therapies. The Clinical Department provides patient follow-up and clinical monitoring with our staff of RN’s, LPN’s and Pharmacists. Their contact with the patient / caregiver and the physician’s office ensures the continuum of care. Clinical Nursing Services When an infusion therapy patient requires clinical nursing services, Home Care Medical can contact the nursing agency and arrange for the provision of needed clinical support services. Selection of the agency is determined by the patient’s insurance coverage, the patient’s preference of agencies, location and agency staff availability. Simply make one call to Home Care Medical and one of our nurses will make the referral to the selected agency and coordinate the initial nursing visit with the delivery of an infusion pump (if needed), supplies and medication. Referring a Patient to Home Care Medical’s Infusion Program To refer a patient to Home Care Medical’s Infusion Program, call: 262.786.9870 ext. 521 and ask to speak to a Clinical Care Coordinator. They will guide you through the referral process, ensuring we have the necessary information to efficiently and professionally continue the care of your patient. Home Care Medical’s Infusion Program is staffed by: – registered pharmacists – pharmacy technicians – registered nurses – nutrition support dietitian – licensed practical nurses – on-call pharmacist and nursing staff available by phone after hours Home Care Medical’s Clinical Pharmacy is accredited by the Joint Commission For More Information, Please Contact: Tom Kmezich, R. Ph Director, Clinical Services 262.957.5549 June 2013

IV Referral Checklist Phone: 262.786.9870 ext 521 | Fax: 262.957.5572 Phase 1: Let’s Get Started

30 minutes

Client Name ________________________________ Acct. Number _____________ Referral Date _ _ _ _ _ _ _ m Demographics Physical Address ___________________________ City, State, Zip Code ________________________ Phone Number (_____)______________________ Caregiver Name ___________________________

Phase 3: Dispense Safely

60 minutes

m Order Therapy _________________________________ Line ___________________________________ Catheter Maintenance Protocol ________________ Labs ___________________________________ m Discharge Date and Time of Last Dose ___________ m Prescriber to Follow After Discharge ___ _ _ _ _ _ _ _ _ _

Caregiver Phone Number (_____)_______________ Emergency Contact Name ____________________ Emergency Contact Phone Number (_____)_______ m Drug ___________________________________

m History and Physical (also line placement report, consult notes, operative summaries and discharge summary, if available) Diagnosis _______________ ICD9_____________ Infectious Conditions _______________________

m Target Discharged Date ______________________

Phase 2: Determine Insurance Coverage 30 minutes m Diagnosis _______________________________ m Dose ___________________________________ m Route __________________________________ m Frequency _______________________________ m Type of Access ____________________________

Other Lines in Place _________________________ m Recent Labs ______________________________ m Medication Reconciliation List (preferred) or Current MAR Current Medication Profile __________ _ _ _ _ _ _ _ _ _ Allergies _________________________________ Height ________________ Weight ____________ m Notes __________________________________ _______________________________________ _______________________________________

Clinical Services Team Directory Phone 262.786.9870 I Fax 262.957.5572 I Back Door Phone 262.957.5212

Pharmacy

Ext

Direct Line

Tom Kmezich, Director of Clinical Services Joe Schueller, Lead Clinical Pharmacist (A-L) Harry Rubin, Clinical Pharmacist (M-Z) Nick Benz, Clinical Pharmacist (M-Z on Friday) Lisa Michaud, Lead Pharmacy Technician Ericka Carnell, Pharmacy Technician II Kandice Cross, Pharmacy Technician II

549 554 575 555 294 311 566

262.957.5549 262.957.5554 262.957.5575 262.957.5555

Infusion Nurses

521

Teresa Nimmer-Vogel, Clinical Care Coordinator Debra Gaulin, Clinical Care Coordinator Jennifer Schneider, Clinical Care Coordinator Katie Murphy, Clinical Care Coordinator Lisa Westphal, FMLH Care Coordinator IV

315 533 583 558

Enteral Nurses

528

Jane Good, LPN Care Coordinator Kim Sewell, LPN, Care Coordinator

550 524

262.957.5550 262.957.5524

510

262.442.9089

262.957.5530

414.805.7323

Nutrition Support Dietician Lynn Koepke, Nutrition Support Dietician

Verification Specialist Sheline Cieczka Valerie Townsend

Last updated June 2013

251 509

Educational Material I Peripherally Inserted Central Catheters (PICC) The peripherally inserted central catheter (PICC) is a long (20-24 inches) intravenous device made of soft flexible material (silicone or a polymer). It is inserted into one of the superficial veins of the peripheral vascular system and advanced into the system. In the adult patient, the basilica vein or median antecubital basilica vein is the preferred site for PICC placement; the cephalic vein may also be used. The catheter tip terminates in the superior vena cava. 1. Indications • • • • • • • • • •

Lack of peripheral venous access. Infusion of hyperosmolar solutions (>25% DSW). Infusion of vesicant drugs. Long term IV therapy in the home, hospital(or clinical setting) Administration of blood or blood products. Infusion of intermittent drug therapy. Use of drug pumps or non-pump pressure delivery systems. Patient preference (body image). Nurse/physician preference. Geographic location.

2. Advantages • • • • • • •

Elimination of risk associated with insertion in the neck and chest region. Potential reduction of catheter sepsis. Decreased pain and discomfort associated with frequent venipunture. Preservation of the peripheral vascular system of the upper extremities. Cost and time efficient. Appropriate for home placement and home IV therapy. Reliable vascular access throughout the course of therapy.

3. Disadvantages • Obscure anatomy. • Infection near insertion point. • Trauma to the antecubita area. • Level of expertise of the insertion personnel.

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Care and Maintenance 1. Cap Change – Minimize the potential for infection and overuse of the cap. A. Supplies: • Alcohol wipes • Sterile cap B. Procedure: 1. Open package. 2. Cleanse outside of the catheter with alcohol wipe. 3. Remove old cap. 4. Remove tip protector from new cap and twist onto hub C. Frequency • 7 days or if leaking, cracking or blood is observed in cap without explanation. • If line is used for Parenteral nutrition. • If cap has been removed for any reason. 2. Dressing Change - Provides sterile environment and prevents catheter migration. A. Supplies: • Sterile gloves • Mask/prn • Alcohol wipe (optional) • Chloraprep swabstick • Gauze or transparent dressing • Tape and/or securing device B. Procedure: 1. Remove old dressing, avoid scissors or excess tugging, pull upward away from exit site. 2. Inspect site for swelling, drainage, redness, change in length of external segment of catheter and suture intactness. 3. Put on sterile gloves. 4. Clean site with Chloraprep swabstick in a back and forth manner. 3. PICC Flushing - Purpose is to maintain patency. • 3-10ml NS before and after use. • Q24 hours according to policy/procedure. • Heparing solution 10 or 100 units/ml 3-5 ml. QD or after each use of any infusates. • Chart date of dressing change and any findings according to policy/procedure. 4. Potential Problems: • Phlebitis-mechanical;48-72 hours post insertion • Infection • Catheter tip migration • Occlusion • Thrombophlebitis • Stuck Catheter (Upon discontinuation Page 2 of 2

PORT-A-CATH® Implantable Venous Access Systems What is a PORT-A-CATH® implatable venous access system? The systems are called implantable venous access systems or, more commonly, an implanted port, because they are placed completely under the skin – usually in a convenient but inconspicuous location on your chest or arm.

How are the systems placed in the body?

Septum

Portal – a small chamber, sealed at the top with a septum made of self-sealing silicone

Catheter Connector – a component that connects the catheter to the portal

Catheter – a thin flexible tube

Implantation of a PORT-A-CATH® system involves a brief surgical procedure. It is placed completely inside the body. One end of the catheter is inserted into the vein, while the other end is connected to the portal, which is placed completely under the skin. The tip of the catheter is located in a vein at a point just above the heart. Once the portal and catheter are in place and the incisions are healed, you will only notice a small bump under your skin. Chest-placed systems

These systems are placed under the skin with the catheter inserted into a vein in the chest. The tip of the catheter is located in the vein at a point just above the heart.

Arm-placed systems

These systems are placed under the skin, with the catheter inserted into a vein in the upper or lower arm. The tip of the catheter is located in the vein at a point just above the heart.

How are medication and fluids delivered through the system? Clinicians can access ports for the delivery of fluids and medications as well as for obtaining blood samples. To access the implanted port, insert a special non-coring needle through skin and the portal septum. Because the needle goes through the skin, patient may feel a pricking sensation. If patient finds the needle insertion procedure uncomfortable, you may want to use a local anesthetic to temporarily numb the skin. This sensation may decrease over time. The medication or fluid flows through the needle, into the portal chamber and through the catheter directly into the bloodstream. The medications or fluids are administered into the system using a syringe, sometimes called IV push, or as a continuous infusion through IV tubing attached to a medication bag with or without the use of an infusion pump.

How to do I clean the site? When a portal access needle is in place, a dressing will cover the needle and portal site. This helps to secure the needle and keep the area clean. The dressing should be kept clean and dry. If a needle is not in place, patient is able to wash and bathe normally. Always inspect the portal area regularly.

How do I flush the systems? The implanted port must be flushed with a heparin solution to prevent blood clots from forming inside the catheter. This created what is usually referred to as a heparin lock. It is recommended that the implanted port be flushed after an infusion or injection, and every four weeks when not in use.

How do I care for a dual lumen port? Caring for a double or dual lumen port is the same as caring for a single lumen port. At times both portal chambers may be accessed simultaneously. Both lumens should also be flushed after an infusion or every four weeks when not in use.

What restrictions do I need to be aware of after the port is implanted? Check with your doctor prior to engaging in activities which involve excessive and/or repetitive motion. Certain occupations, or physical activities, such as golfing, swimming or lifting may increase the possibility of catheter damage, i.e. fragmentation.

Can patient have an MRI with an implanted port in? Smiths Medical’s implantable ports are constructed of various materials and are labeled as MRI conditional. This means that they may safely undergo magnetic resonance (MR) imaging using MR systems with static magnetic field strengths of 3.0 Tesla or lower. Patient will be asked about any implanted devices prior to receiving an MRI.

Can implanted ports go through airport security? Airport metal detectors will not harm a PORT-A-CATH® system. In most situations, the PORT-ACATH® device will not set off the airport metal detectors. However, the sensitivity of metal detector varies. Inform the patient that the total amount of incidental metal he/she may be wearing (jewelry, watches, zippers, coins, etc.) may be enough to set off the metal detector. Recommend that the patient carry their identification card that was provided.

Wallet size id

What are the most common types of ports? PORT-A-CATH®

PORT-A-CATH® ll

P.A.S. PORT® Elite system

Pro Port® system

Additional guidelines for caring for your implanted port • •

Do not tilt or rock the needle once it is inserted. Do not leave the needle or attached tubing open to the air while the needle is inside the portal.

Potential complications Use PORT-A-CATH® implanted port systems involve potential risks normally associated with the insertion or use of any implanted device or indwelling catheter, including catheter disconnection or fragmentation with possible embolization of catheter. Illustrations and instructions provided by Smiths Medical ASD, Inc. Smiths Medical ASD, Inc., is a registered trademark of Smiths Medical family of companies.

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Corporate Headquarters 5665 South Westridge Drive Suite 100 New Berlin, WI 53220 Ph 262.786.9870, ext. 521 Fax 262.957.5572 homecaremedical.com

Educational Material I Tunneled (Hickman) Catheter Care A tunneled catheter is an intravenous device made of soft flexible material (silicone or a polymer.) One end is inserted into the superior vena cava via the subclavian vein and the other end is tunneled subcutaneously for several inches until it exits the skin, usually on the upper chest. A Dacron cuff attached to the catheter assists in securing the catheter in place through the growth of fibrous tissue. The cuff also helps reduce the potential for infection caused by the migration of bacteria along the tunneled catheter. 1. Indications • Lack of venous access • Infusion of hyperosmolar solutions (>25%D5W) • Infusion of vesicant drugs and chemotherapy agents • Long term IV therapy in the home, long term care facility or hospital • Administration of blood products • Infusion of intermittent drug therapy

Care and Maintenance

1. Cap Change - Purpose is to minimize the potential for infection and overuse of the cap. A. Supplies • Alcohol wipe • Sterile cap B. Procedure 1. Open package. 2. Cleanse outside of catheter with alcohol wipe. 3. Remove old cap. 4. Remove tip protector from new cap and twist onto hub. C. Frequency • Q7 days and prn if leaking, cracking or blood observed in cap without explanation. • Twice weekly when line is used for parenteral nutrition. • If cap has been removed for any reason. 2. Catheter Flushing – Purpose is to maintain patency. A. Supplies • Alcohol wipe • Heparin 100units/ml 3-5ml per day and after each use. • NS 3-5ml before and after medications. • NS 10ml after blood draws. 3. Dressing Change - Purpose is to prevent infection. A. Supplies • Sterile gloves Page 1 of 2

• Mask • Chloraprep swabstick • Gauze or transparent dressing • Tape B. B) Procedure 1. Remove old dressing, avoid scissors and excess tugging. Pull upward and away from exit site. 2. Inspect site for swelling, drainage or redness. 3. Cleanse site with chloraprep swabstick in a back and forth manner. 4. Allow chloraprep to dry 5. Apply gauze or transparent dressing. 6. Loop catheter and tape securely to dressing or skin. C. Frequency • 24 hours after insertion/catch, contain and control drainage. • 2 weeks according to policy/procedure or prn if non-occlusive, soiled or wet. • Chart date of dressing change and any finding according to policy/procedure. 4. Troubleshooting A. Aspiration difficulties • Failure to flush resulting in lumen obstruction. • Blood clot fibrin sheath, or particulate matter obstructing the valve. • Compression of the catheter between the clavicle and the first rib (“pinch-off syndrome”). • Kinked catheter outside or inside the body. • Suture constriction at exit site or at cuff inside, or vessel insertion point. • Catheter may be curled or kinked within the vessel. • Malposition of catheter (jugular vein or outside vessel). B. Possible Solutions • Visually check catheter for kinks or sutures drawn too tight. • Attempts to flush w/ 10ml NS vigorously. • If no resistance is felt, continue flushing. • If resistance is met, attempt to draw back on syringe plunger 2-3ml, pause and proceed with aspiration. • If resistance is still felt, check for signs of extravasation. If present, notify MD according to policy and procedures. • Attempt to aspirate with 20ml syringe to create a greater vacuum. • Move patient arm, shoulder and head to see if a position change will allow aspiration.

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Educational Material I Continuous Subcutaneous Infusion 1. Obtain supplies below: • Subcutaneous needle - subcutaneous needle set • Chloraprep swabs (1) • Alcohol swabs (1) • Infusion pump • Bag with medication for infusion • Transparent occlusive dressing • Needle bucket 2. Check medication label for correct name, drug, rate and expiration date. 3. Wash hands following handwashing procedures. 4. Attach medication (bag or cassette) on to pump as instructed. 5. Attach subcutaneous needle to end of IV tubing. Prime to expel the air in the tubing subcutaneous set until you see fluid at the end of the needle. 6. Turn on pump and prime to expel all the air in the tubing and needle. Once you see fluid at the end of the needle, turn pump off. 7. Choose injection site, using anterior thighs, lateral abdomen or the outer side of the upper body surface. 8. Clean the injection site with chloraprep, allow drying. 9. After cleansing, pinch up the tissue and carefully insert the needle at the appropriate angle need. If using a button-type subcutaneous needle set, insert at a 90 degree angle. 10. Cover with transparent occlusive dressing to anchor. With sof-set subcutaneous needle insertions, remove introducer and place in needle bucket prior to applying dressing. 11. Start the pump as directed. 12. Observe injection site for swelling, hardness, bleeding, redness or pain. This may indicate need for site change. The recommended needle and site change is every three days or more often as needed. 13. If injection site becomes more red and painful after discontinuation, notify your physician. 14. Monitor response to drug therapy and notify doctor as needed. Page 1 of 2

http://www.marcalmedical.com/subQsafetySubQ.htm

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Educational Material I Peripheral Cannula Insertion Anatomy

1. Skin A. Epidermis • Uppermost layer that forms a protective covering for the dermis. • Thickness varies in different parts of the body. • Thickest on the palms of the hands and the soles of the feet. • Thickness varies with age. • In the elderly patient, the skin on the dorsum of the hand may be so thin that it does not adequately support the vein for venipuncture when infusions are required. B. Dermis • Under layer. Highly sensitive and vascular. • Contains many capillaries and thousands of nerve fibers. • These fibers are of different types and include those that react to temperature, touch, pressure and pain. • Some parts of the body are more sensitive than others. • The inner aspect of the wrist is a more sensitive area. • Venipuncture should only be done on inner aspect of wrist as last resource. C. Superficial fascia. Connective tissue lies below the other: • Fascia or connective tissue lies below the other two layers of skin and is another covering. • It is in this fascia that the superficial veins are located. • It varies in thickness. • When a cannula is inserted into this fascia, there is free movement of the skin above. • Aseptic technique is vital because an infection in this loose tissue can spread easily: this is called cellulitis. D. Vein selection (see handout) • Metacarpal veins of the hand • Basilic veins • Cephalic veins • Median veins

Guidelines

1. INS A. Provides educational, experiential and technical criteria for establishing levels of competence within the practice of infusion therapy. 2. OSHA A. Bloodborne pathogen standards are followed when initiating IV therapy. B. Personal protective equipment should be used to reduce the risk of exposure to blood or other infectious materials. C. Gloves, face shields, goggles and gown are to be used according to agency policy. Page 1 of 5

3. Equipment selection A. Metal cannula (butterfly) • Used for short infusions or blood sampling. • Rigid and can infiltrate easily if not secured well and assessed frequently. B. Polymer Cannula • Radiopaque catheters made of materials that reduce thrombosis and promote patient safety. • Easily available and can be inserted with ease for patient comfort. 4. Reducing risks of exposure A. Proper disposal of equipment. B. One-handed technique for re-capping. C. Safety needles. D. Protective gear (universal precautions). 5. Reducing the risks of infection A. Hand washing at least 15 seconds with an antimicrobial soap. B. Wash hands before and after wearing gloves. C. Prepare clean work area. D. Use of protective barrier/drape underneath arm. E. Proper storage of equipment. F. Dispose any equipment whose packaging looks suspicious. G. Proper site preparation with antimicrobial cleanser. H. Proper site care. 6. Venipuncture A. Helpful hints for successful venipuncture (see handout) B. Procedure 7. Potential complications (see chart).

Peripheral Vein Selection for IV Therapy 1. Consider the length of therapy, level of cooperation from the patient and the characteristics of the drug when selecting a vein. 2. Preferred veins are the basilic and cephalic veins. The median antebrachial, median cubital and metacarpal veins may also be used. 3. Veins in the forearm are fairly straight, visible and easily stabilized with the thumb. 4. Use distal veins first. 5. Use the arm least used by the patient. 6. Avoid veins located in areas of flexion. 7. Avoid previously used veins, injured veins and sclerotic veins. Page 2 of 5

8. Avoid veins in the affected arm of an axillary dissection. 9. Avoid veins showing marked varicosities at or above the injection site. 10. Avoid the stroke-affected side. 11. Avoid the arm with an A-V shunt. 12. Veins in lower extremities are used as a last resort due to increased risk of thrombophlebitis and embolism. Obtain physician’s orders to use veins of the lower extremities.

Suggested Venipuncture Technique 1. Assemble equipment tourniquet • Tape • Skin prep • Drape • Sterile gloves • IV cannula • Scissors (to clip hair, if needed) • Primed infusion set or injection site cap • Dressing (transparent or gauze) 2. Wash hands with antimicrobial soap for 10-15 seconds,or per agency policy. 3. Apply tourniquet approximately 2-6 inches above the preferred site. 4. Select the vein. 5. Apply gloves. 6. Prepare the site. • Clip excessive hair with scissors; do not shave. • Clean with alcohol first. Apply in circular motion working from center outwards for 2”, for 30 seconds. • Clean with povidone iodine for 30 seconds and allow to dry without blowing or fanning. • Dab off excess with a sterile gauze pad. Do not remove PI with alcohol. 7. Remove the protective cover from the IV needle and inspect the catheter. • Bevel must be up. • If using an over the needle cannula, make sure the stylet extends beyond the plastic cannula. • Catheter must be smooth. 8. Anchor the vein by maintaining good traction on the skin. 9. Approach the vein at a 20-40 degree angle until a "pop" is felt and blood return is seen. • Decrease the angle and thread another 1/4 inch into the vein. • Hold the stylet stationary and advance the catheter only. Never reinsert the stylet into the catheter. Page 3 of 5

10. Release the tourniquet. 11. Remove the stylet while applying pressure proximal to the tip of the catheter to prevent blood spillage. 12. Connect the tubing or prn adapter. 13. Tape securely and label, as appropriate.

Helpful Hints for Successful Venipuncture

1. To distend the peripheral circulation, do the following: A. Apply tourniquet 2-6” above the insertion site. B. Have patient clench and unclench the fist with tourniquet in place. C. Apply warm compress to site for 10-15 minutes prior to venipuncture. D. Allow arm to hang below the level of the heart. E. Make sure patient is not cold or tense. F. Gently tap the vein. G. With tourniquet on, gently massage the area in opposite direction of venous flow. 2. Use your thumbs to "push" edema from the site in order to better visualize the vein. 3. Be sure the tourniquet is tight enough, but not so tightly that arterial circulation is cut off. 4. Veins located on the underside of the arm can be used if necessary. 5. Use the smallest gauge catheter that will achieve the desired flow rate and allow the greatest amount of blood flow around the catheter.

Discontinuing an IV Needle or Catheter 1. Wash hands and put on gloves. 2. Carefully remove the tape and dressing securing the catheter. 3. Place sterile gauze over the injection site. 4. While gently applying pressure over the injection site, pull out the catheter smoothly and straight backward, taking care to not raise up the needle before it is out of the arm. 5. When removing the catheter, always check to be sure that all of it has been removed. 6. Examine the site for evidence of bleeding after about one minute. Continue pressure until bleeding stops. Elevate the arm above the level of the heart if necessary to control bleeding. 7. Apply band-aid or gauze dressing after bleeding has stopped. 8. Instruct patient and/or caregiver to observe site for bleeding or signs of infection and to limit activity with the IV arm for 24 hours.

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BD Angiocath™ Autoguard™ Shielded IV Catheter

Suggestions for Use CLINICIANS MUST BE TRAINED IN THE PRACTICE OF VENIPUNCTURE AND BE AWARE OF INHERENT DANGERS. Aseptic technique, proper skin preparation and continued protection of the site are essential. Observe Universal Precautions on ALL patients. A. Remove needle cover in a straight outward motion and inspect catheter unit. Rotate catheter 360°. B. Perform venipuncture. C. Observe blood return. 20, 22, 24 GA: blood return will also be visible through the catheter. Lower and advance catheter unit 1/8”. D. Holding the flash chamber stationary, advance the catheter off the needle into the vein. E. Before withdrawing needle from the catheter, depress button to retract the needle into the clear safety shield. Immediately discard unit in a puncture resistant, leak proof sharps container. If needle retraction does not occur, depress button again. Dispose of any unshielded needles immediately. Keep needlepoint away from body and fingers at all times. F. Connect tubing or adapter. NEVER REINSERT THE NEEDLE INTO THE CATHETER DO NOT BEND THE NEEDLE WHILE USING THE PRODUCT G. Secure catheter and dress site per protocol. NOTE: 18 to 22 gauge are suitable for use with power injectors rated for a maximum of 300 psi. NON PYROGENIC-STERILE. DO NOT use scissors at or near insertion site. Re-use may lead to infection or other illness/injury. DEHP free. This product does not contain natural rubber latex.

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Educational Material I Supplies & Usage Guidelines Normal Saline:

A. 5ml or 10ml prefilled syringes. B. 30ml multi use vial. Attach 1 vial adapter per vial for duration of use. Access with luer-lock syringe. Heparin: A. 3ml or 5ml prefilled syringes. B. 10 units or 100 units. 30ml multi use vial. 10 unit or 100 unit. Higher doses are available. Attach 1 vial adapter per vial for duration of use. Must be refrigerated expires after 14 days. Vanco Heparin Flush: Mixed in pharmacy. Expires after 14 days. 30ml vial. Need to use a vial adapter (1 per vial) with a luer-lock syringe. Must be refrigerated. Vial Adapter: For use with NS, Heparin & Vanco-Heparin vials access with 10ml luer lock syringe. 1 adapter per vial. Syringes: Sizes: 1ml Tuberculin, 3ml, 5ml, 10ml, 20ml, 30ml, and 60ml. Dressing change kit: Use 1 per week. Contents: 1 CSR wrap, 1 mask, 2 pair walleted gloves, 1 chloraprep one-step applicator, 1 chloraprep insert, 1 3pk alcohol swabsticks, 2 4x4 gauze sponges, 1 transparent dressing. *Grip-lok: Use 1 per week. If line is sutured then do not need to use a securement device. *Microclave: Change once a week or after lab draws. Change twice a week if patient is on TPN therapy Extension sets: 7 inch or 15 inch. Change once a week. Y-Site: If using Y-site be sure to check if drugs are compatible if they are running together. *Flow regulator tubing: Locate flow regulatoron tubing to set rate. Can’t run SQ. Use 1 tubing for 24 hours per drug. Put a red cap on end of tubing between doses if multiple doses per day. Vista tubing: Can use with Vista pump or as gravity. If using with Vista pump be sure the roller clamp is below the pump. Use 1 tubing for 24 hours per drug. Put a red cap on end of tubing between doses. Red Caps: Put on the end of tubing between doses. Tubing is to be used: 1 tubing every 24 hours per drug. *Peripheral IV needles: Insyte Autoguard 20g 1.16”, 22g 1”, or 24g ¾” or Saf-T-Intima 22g ¾”. Will send a few extra with initial order in case it is a difficult start. Change catheter every 72 hours. IV start kit: 1 pair gloves, 1 tourniquet, 1 roll tape, 1 PVP prep pad, 1 alcohol prep pad, 2 2x2 gauze sponges, 1 tegaderm dressing, 1 label. Huber needles: Non-coring. 1 inch, ½ inch or ¾ inch. Change once a week. *SQ set: MarCal SQ. Change every 72 hours or per protocol. Contamination Usually send 2 gallon size. If we have equipment to pick up at end of container: therapy we can take the contamination container also. Patient will have to have it snapped shut for driver to take it. Driver needs to have instruction from us to pick up container. * Picture/Instructions available (see attached).

Application of Grip-Lok WA (Wide Adhesive) for PICC Catheter Securement

Catheter Securement

Grip-Lok WA (3300M WA) is a catheter stabilization device that is strong enough to lock catheters securely in place, yet versatile enough for almost any securement situation. The adhesive on Grip-Lok WA will adhere and secure catheters made from silicone, PVC and other plastic compounds. • Soft and flexible fabric design improves patient comfort. • Provides superior securement for both horizontal and vertical lifting accidental line pulls. • Simple to apply apply, inspect and adjust adjust. • Hypoallergenic, breathable and latex-free to reduce the risk of allergic reactions and skin irritation.

Prepare the skin is according to the standard hospital protocol for dressing application. Skin prep or hair removal may be required on some patients for better adhesion.

1

Open the top flap and slide the Grip-Lok under the catheter, tube or line, centering it above the adhesive area.

3

Remove the inside liner labeled PULL to expose the adhesive areas.

2

Pull the paper backing from one side of the Grip-Lok, then the other, to secure in desired position on the skin.

4

Place the catheter, tube or line on the bottom adhesive area and secure top flap over the catheter, tube or line.

Grip-Lok WA will secure a wide variety of catheter hub sizes and shapes. shapes

MM00016 Rev1

www.zefon.com

Reference Guide for

MicroClave® Neutral Displacement Connector

Directions for Use Disinfect to Protect >> When placing a new MicroClave on a catheter, disinfect the catheter hub and prime the MicroClave. >> Before accessing a MicroClave, always disinfect the injection site with the approved antiseptic per facility protocol. >> Scrub the injection site in accordance with facility protocol for appropriate scrubbing and dry times.

Administer or Aspirate >> Attach IV tubing, syringe or blood tube holder to MicroClave by inserting the luer and twisting ¼ turn, or until a friction fit is achieved. >> Do not over-tighten a luer beyond the friction fit as this may damage both the luer and the MicroClave. >> To disconnect, grasp MicroClave and then twist mating luer away from MicroClave until loose. Do not hold catheter hub during disconnect as this may cause accidental removal of MicroClave from hub.

Flush After Each Use >> Flush the MicroClave with normal saline or in accordance with facility protocol. After blood use, the MicroClave can be flushed clean and does not require change-out. >> Use routine flushing in accordance with facility protocol in order to maintain catheter patency. >> Change MicroClave in accordance with facility protocol and CDC Guidelines.

Functional Attributes >> Lipid and Blood Compatible >> Radiographic Imaging Compatible (CT Compatible) >> Contains No Latex, Phthalate’s (DEHP) or Metal

Components, MRI Compatible

© 2011 ICU Medical Inc.

M1-1198 Rev. 05

MicroClave’s saline flush option can eliminate the risk of Heparin Induced Thrombocytopenia (HIT).

Home Care Medical

Flow Regulator I.V. Administration Set Instructions for Use 1. Always use a aseptic technique. 2. Prepare IV container. 3. Remove Infusion set from the package. 4. Close the pinch clamp. 5. Remove the spike cover and insert the spike into the spike port of the IV container. 6. Hang the IV container, squeeze the drip chamber until it is half full. 7. Slowly open the pinch clamp to prime the tubing and fiter. 8. Remove the distal male luer cap to purge all air from the IV set, tap the “Y” site to remove air. 9. Close the pinch clamp, connect the male luer to patient’s vacular access apparatus. 10. Open pinch clamp, adjust the drop rate to desired flow. 11. Check for leaks or blockage. 12. Replace per CDC guidelines or facility protocols. Instructions provided by Medical Specialties Distributers, LLC.

Home Care Medical… helping you get on with life!

Corporate Headquarters 5665 South Westridge Drive Suite 100 New Berlin, WI 53220 Ph 262.786.9870, ext. 521 Fax 262.957.5572 homecaremedical.com

FAQ’s regarding HCM’s VAD Maintenance Guidelines for Adults Q: Why does HCM have a new protocol for catheter maintenance? A: In 2011, the Infusion Nursing Standards of Practice for the maintenance of vascular access devices were revised. HCM’s new protocol reflects the updated guidelines for maintaining lines in the home care setting. Q: What does HCM do when the prescriber’s order differs from the protocol? A: The protocol does not replace patient specific orders. When a prescriber writes specifically for saline flushes, heparin locks, or other alternative flushing and/or locking solutions, the prescriber’s order will be followed as written. Q: Why does HCM’s protocol differ from other agencies’ protocols? A: HCM’s protocol is based on the 2011 INS Standards of Practice as well as manufacturer specific recommendations. While we cannot comment on the rationale of another agency’s protocol, we are interested in local collaboration in an attempt to achieve continuity in the community. Q: What if a particular field nurse isn’t familiar with HCM’s protocol? A: While we would like all nurses caring for our patients to be familiar with the protocol, they do not necessarily have to be; as with any prescription drug, they just need to follow the instructions provided on the label. Of note, the label may reflect patient specific orders, HCM’s protocol or even the nursing agency’s protocol. The only way to know how to maintain a particular patient’s line is to read the label. Q: Are existing patients going to have to be re-taught based on the new flushing guidelines? A: Existing patients will continue to maintain their lines according to the current prescription that is on file. Prescriptions will only be updated if the patient is experiencing a problem that would warrant a change (i.e.: loss of patency and/or catheter infection). Q: What about home care nurses and/or patients that won’t use HCM’s protocol because they have their own way of doing it? A: Saline and heparin are prescriptions, so ultimately, the order has to be followed whether it was written as a patient specific order or per protocol. It is the nurses’ and patients’ responsibility to read and follow the instructions on each and every prescription label. Q: Don’t you need heparin to maintain a short peripheral line? A: According to the INS, short peripheral catheters should be locked with NS following each catheter use. Q: When maintaining a line in the home care setting, don’t you need to use saline prior to heparin? A: Saline is for before and after drug or blood only. Saline is used before to check catheter function and after to clear the catheter of drug or blood. For maintenance without infusion, it is appropriate to use heparin only. Heparin locks are actually “heparinized saline” and can be thought of as a 2-in-1 product. (A small amount of saline will always be provided for the home care nurse to use when drawing blood, priming the extensions/caps and assessing/troubleshooting the line.) Home Care Medical, Inc., New Berlin, WI

December 2011

VAD Maintenance Guidelines for Adults

Medication Management 2011 JC MM.04.01.01, 05.01.01, 5.01.11, 08.01.01

Clinical P-50 Revised 11/24/11 Effective 1/01/12

NOTE: This summary of flushing, locking and dressing change standards is not intended to replace patient specific orders or manufacture specific recommendations. VAD maintenance requires a prescription. If the prescriber orders the use of standard policies/procedures or “per protocol”, follow these guidelines. If provided, following the guidelines of the home infusion nursing agency may also be acceptable. VAD

NS flushing with infusion

NS flushing with blood

Short peripheral catheter

Minimum 2 ml before and after (at least Q12H)

Minimum none 2 ml before and 10 ml after

NS 2 ml Q12H

Midline catheter

Minimum 3 ml before and after

Minimum 3 ml before and 10 ml after

10 units/ml 3 ml after each use (at least Q12H)

Heparin 10 units/ml 3 ml Q12H (NS not necessary)

10 units/ml 5 ml after each use (at least Q12H)

Heparin 10 units/ml 5 ml Q12H (NS not necessary)

10 units/ml 5 ml after each use (at least Q24H)

Heparin 10 units/ml 5 ml Q24H (NS not necessary)

10 units/ml 5 ml after each use (at least twice weekly)

Heparin 10 units/ml 5 ml twice weekly (NS not necessary)

PICC

Nontunneled CVAD

Minimum 5 ml before and after

Tunneled CVAD

Minimum 5 ml before and 20 ml after

Heparin locking

Maintenance without infusion

Additional information

Routine dressing changes not performed unless soiled or no longer intact.

Change transparent dressing Q7D or gauze dressing Q2D. .

Page 1 of 5 Home Care Medical, Inc., New Berlin, WI

VAD Maintenance Guidelines for Adults

VAD

Implanted port

Medication Management 2011 JC MM.04.01.01, 05.01.01, 5.01.11, 08.01.01

NS flushing with infusion

NS flushing with blood

Minimum 5 ml before and after

5 ml before and 20 ml after

Hemodialysis and apheresis catheters

Heparin locking

10 units/ml 5 ml after each use 100 units/ml 5 ml prior to removal of needle and monthly

Clinical P-50 Revised 11/24/11 Effective 1/01/12

Maintenance without infusion

Additional information

Heparin 100 units/ml 5 ml monthly

Change needle Q7D. Change transparent dressing Q7D or gauze dressing Q2D.

1000 units/ml after each use

Flushing and Locking Standards: • Vascular access devices shall be flushed before each infusion as part of the steps to assess catheter function. • Vascular access devices shall be flushed after each infusion to clear the infused medication from the catheter lumen, preventing contact between incompatible medications. • Vascular access devices shall be locked after completion of the final flush to decrease the risk of occlusion. Practice Criteria: A. Single use systems including single-dose vials and prefilled syringes are the preferred choice for flushing and locking and should be used whenever possible. B. Preservative-free 0.9% sodium chloride (PF NS) is used for flushing. When the medication is incompatible with PF NS, 5% dextrose in water should be used and followed by flushing with PF NS and/or heparin lock solution. Dextrose should be flushed from the lumen because it can provide nutrients for biofilm growth. C. Solutions containing the preservative benzyl alcohol, including Bacteriostatic NS, should be avoided for flushing and/or locking catheters as the maximum tolerated daily volume is undetermined; however, one study suggests that this should not exceed 30 mL in a 24-hour period for adults and should never be used in neonates. D. The minimum flush volume is twice the internal volume of the catheter plus any add-on device; a larger volume may be needed for blood sampling or blood transfusion procedures. Page 2 of 5 Home Care Medical, Inc., New Berlin, WI

VAD Maintenance Guidelines for Adults

Medication Management 2011 JC MM.04.01.01, 05.01.01, 5.01.11, 08.01.01

Clinical P-50 Revised 11/24/11 Effective 1/01/12

E. Positive fluid displacement should be maintained by using a needleless connector designed to overcome blood reflux and by not flushing all the fluid from the syringe. F. The nurse should aspirate the catheter for blood return as a component of checking catheter function with each assessment visit (during the weekly dressing change). G. If resistance is met and/or no blood return is noted, the nurse should take further steps to assess patency of the catheter prior to administration of medications. The catheter should not be forcibly flushed. H. To prevent catheter damage, midlines and CVADs should only be flushed with a minimum 10 ml syringe. I. The connector surface must be scrubbed for 10-15 seconds with a new alcohol pad prior to each use. For the SASH procedure, this means using four alcohol pads, one before each of the four steps in the procedure. J. Prefilled PF NS syringes should not be used for dilution of medications. Due to risk of serious medication errors, syringe-to-syringe drug transfer is not recommended. K. All patients should be monitored closely for signs and symptoms of heparin-induced thrombocytopenia (HIT). If present or suspected, all sources of heparin should be discontinued. L. Postoperative patients receiving heparin lock solutions of any concentration should have platelet counts monitored every 2-3 days until heparin is stopped. This does not apply to nonpostop medical patients. M. Available data is inconclusive and conflicting regarding the use of NS for locking catheters with an integral pressure-sensitive valve system (e.g. closed system, Groshong, SOLO, PASV). Due to the risk and costs associated with insertion, heparin lock solution 10 units/mL is the preferred lock solution after each intermittent use for all CVADs. N. Alternative locking solutions may be considered in patients with HIT including ethanol, sodium citrate, taurolidine, and/or ethylenediamine-tetraacetate (EDTA). O. While use of antibiotic lock solutions is not recommended as a routine prophylactic measure, they may be considered in patients with a history of catheter-related bloodstream infections, with other risk factors such as a prosthetic heart valve, or to salvage an infected long-term CVAD. Definitions: Vascular access device (VAD): a catheter that is inserted into the vascular system, including veins, arteries, and bone marrow. Short peripheral catheter: a VAD with the distal tip terminating in a peripheral vein. Appropriate for therapies lasting < 1 week. Peripheral administration—not appropriate for vesicants, parenteral nutrition, infusates with pH 9 or osmolalities > 600 mOsm/L.

Page 3 of 5 Home Care Medical, Inc., New Berlin, WI

VAD Maintenance Guidelines for Adults

Medication Management 2011 JC MM.04.01.01, 05.01.01, 5.01.11, 08.01.01

Clinical P-50 Revised 11/24/11 Effective 1/01/12

Midline catheter: a VAD measuring 8 inches or less with the distal tip dwelling at or below the axillary line. Appropriate for therapies lasting 1-4 weeks. Peripheral administration—not appropriate for vesicants, parenteral nutrition, infusates with pH 9 or osmolalities > 600 mOsm/L. Central vascular access device (CVAD): a device that permits access to the central vascular system. A catheter with the tip residing in the lower one-third of the superior vena cava, or above the level of the diaphragm in the inferior vena cava. Appropriate for short- or long-term therapies including antineoplastics, vesicants or known irritants, parenteral nutrition, and medications with pH of < 5 or > 9 and osmolarity of greater than 600 mOsm/L. Peripherally Inserted Central Catheter (PICC): a CVAD inserted into an extremity and advanced until the tip is positioned in the vena cava. Nontunneled CVAD: a CVAD inserted in the subclavian, jugular or femoral veins. Tunneled CVAD: a surgically placed CVAD whose proximal end is tunneled subcutaneously from the insertion site and brought out through the skin at an exit site. Implanted port: a CVAD that is surgically placed into a vessel and is attached to a reservoir located under the skin. Flushing: moving fluids out of a VAD and into the bloodstream, ensuring delivery of those components and verifying device patency. Locking: the instillation of a solution into a VAD to maintain device patency. Heparin-Induced Thrombocytopenia (HIT): a potentially life-threatening immunologic reaction caused by platelet activation resulting in a hypercoagulable state with strong association to vascular and arterial thrombosis as a result of heparin exposure. Sample Instructions: Short peripheral catheter: Flush catheter with NS 2-10 ml before and after each infusion and at least every 12 hours when not in use to maintain patency. Flush with NS 2-10 ml before and 10 ml after each blood draw, if ordered. Midline catheter: Flush catheter with NS 3-10 ml before and after each infusion. Flush with NS 3-10 ml before and 10 ml after each blood draw, if ordered. Page 4 of 5 Home Care Medical, Inc., New Berlin, WI

VAD Maintenance Guidelines for Adults

Medication Management 2011 JC MM.04.01.01, 05.01.01, 5.01.11, 08.01.01

Clinical P-50 Revised 11/24/11 Effective 1/01/12

Lock catheter with Heparin 10 units/ml 3-5 ml after each use and at least every 12 hours when not in use to maintain patency.

PICC: Flush catheter with NS 5-10 ml before and after each infusion. Flush with NS 5-10 ml before and 10 ml after each blood draw, if ordered. Lock catheter with Heparin 10 units/ml 5 ml after each use and at least every 12 hours when not in use to maintain patency. Nontunneled CVAD: Flush catheter with NS 5-10 ml before and after each infusion. Flush with NS 5-10 ml before and 10 ml after each blood draw, if ordered. Lock catheter with Heparin 10 units/ml 5 ml after each use and at least every 24 hours when not in use to maintain patency. Tunneled CVAD: Flush catheter with NS 5-10 ml before and after each infusion. Flush with NS 5-10 ml before and 10 ml after each blood draw, if ordered. Lock catheter with Heparin 10 units/ml 5 ml after each use and at least twice weekly when not in use to maintain patency. Implanted port: Flush port with NS 5-10 ml before and after each infusion. Flush with NS 5-10 ml before and 10 ml after each blood draw, if ordered. Lock port with Heparin 10 units/ml 5 ml after each use. Lock port with Heparin 100 units/ml 5 ml prior to removal of access needle and monthly when not in use to maintain patency. Resources Infusion Nurses Society; Standards of Practice. J Infus Nurs. 2011;34(1S):S37-S64. BARD Access Systems. BARD Family of PICCS Care and Maintenance Guide. http://www.bardaccess.com/assets/pdfs/other/MC-008401_PICC_and_Maintenance_Guide_web.pdf. Accessed December 1, 2011. BARD Access Systems. PerQCath Midline IFU. http://www.bardaccess.com/assets/pdfs/ifus/0714368-3132100-PerQCath-Midline-Cath-IFUweb.pdf. Accessed December 1, 2011.

Page 5 of 5 Home Care Medical, Inc., New Berlin, WI